Skills Lab Midterm Exam (Weeks 1-6)

CrCl → Cockcroft-Gault Equation (male)

CrCl = (140 - Age) x Weight in kg / 72 x SCr

CrCl → Cockcroft-Gault Equation (female)

CrCl = 0.85 x [(140 - Age) x Weight in kg / 72 x SCr]

In the Cockcroft-Gault equation, what will the SCr value be rounded to for a patient whose 65 years and older?

1.0

How to calculate IBW_male 

IBW = 50kg + 2.3kg for each inch over 5 feet

How to calculate IBW_female

IBW = 45.5kg + 2.3kg for each inch over 5 feet

How to calculate AdjBW

AdjBW = IBW + 0.4 (ABW - IBW)

How to calculate BMI

BMI = lbs / in² (703)

When do you use ABW as the ‘Wt’ in CrCl equation?

When the patient’s BMI indicates underweight → BMI < 18.5

When do you use IBW as the ‘Wt’ in CrCl equation?

When the patient’s BMI indicates normal weight → BMI < 25

When do you use AdjBW as the ‘Wt’ in CrCl equation?

When the patient’s BMI indicates overweight/obesity → BMI >/ 25

What is a sphygmomanometer used for measuring?

BP

How to get an accurate BP reading

1. Empty bladder first (full bladder adds 10 mmHg)

2. Support back/feet (unsupported back/feet adds 6.5 mmHg)

3. Keep legs uncrossed (crossed legs add 2-8 mmHg)

4. Don’t have a conversation (talking or active listening adds 10 mmHg)

5. Put cuff on bare arm (cuff over clothing adds 5-50 mmHg)

6. Use correct cuff size (cuff too small adds 2-10 mmHg)

7. Support arm at heart level (unsupported arm adds 10 mmHg)

When should a patient have a follow-up when having their bp taken?

2 weeks (1 week if bp is abnormally high)

What factors will affect a bp reading when occurred within 30 minutes of taking bp?

• Physical activity

• Smoking (nicotine)

• Caffeine

• Stress

What does IPPA stand for?

Inspection

Palpation

Percussion

Auscultation

What is the main purpose of the pharmacist performing physical exams?

To evaluate and monitor drug therapy

Which of the following best describes systemic blood pressure?

a. Pressure in the arteries during cardiac relaxation

b. Pressure in the veins when the heart stops

c. Force of blood during cardiac contraction

d. Pressure different between arteries and veins

c. Force of blood during cardiac contraction

The auscultatory gap refers to:

a. The point when no sounds are heard because of equipment malfunction

b. The temporary disappearance of Korotkoff sounds during BP measurement

c. A difference between systolic and diastolic pressures

d. A silent pause caused by rapid cuff deflation

b. The temporary disappearance of Korotkoff sounds during BP measurement

When deflating the cuff during BP measurement, the first Korotkoff sound corresponds to:

a. Diastolic pressure

b. Mean arterial pressure

c. Systolic pressure

d. Pulse pressure

c. Systolic pressure

T/F: Palpation involves tapping on a surface to determine underlying structures.

False

• That’s percussion; palpation involves touching/feeling

T/F: The cuff pressure must exceed brachial artery pressure to temporarily stop blood flow during BP measurement.

True

T/F: A true BP reading is recorded at the start of two consecutive beats.

True

The two main components of BP are ______ and _______.

Systolic; diastolic

The purpose of a SOAP note is to accurately document the patient’s Subjective, Objective, Assessment, and _______ data.

Plan

Pharmacists’ Patient Care Process: ‘Collect’

The pharmacist ensures the collection of necessary subjective and objective information about the patient to understand the relevant medication and medical history, overall health status, and other pertinent factors.

• Information may be gathered and verified from multiple sources

  • Patient

  • Caregiver

  • Observations

  • Existing patient records

  • Health care professionals

Pharmacists’ Patient Care Process: ‘Assess’

The pharmacist assesses the collected information to identify and prioritize patient needs to inform the establishment of a care plan.

Pharmacists’ Patient Care Process: ‘Plan’

The pharmacist develops a person-centered, evidence-based, cost-conscious care plan in partnership with the patient and/or caregiver, and in coordination with other care team members.

Pharmacists’ Patient Care Process: ‘Implement’

In providing person-centered care, the pharmacist implements a prioritized care plan in partnership with the patient and/or caregiver and in coordination with other care team members.

Pharmacists’ Patient Care Process: ‘Follow Up: Monitor and Evaluate’

The pharmacist follows up to monitor and evaluate the implementation of the care plan and the patient’s overall health in collaboration with the patient, caregiver, and other care team members, as needed.

Sleuthing

• Evaluate and monitor drug treatment

• Identify drug-related problems

• Resolve drug-related problems

• Select the best drug-treatment option

What is blood pressure?

Force of blood as it pushes against the arterial walls

Dependent on 2 things:

• Cardiac output

• Resistance

Systolic pressure

Pressure during contraction

Diastolic pressure

Filling pressure

What do you hear when taking bp?

1. Air into cuff raises pressure in the cuff

2. Cuff pressure exceeds the pressure in the brachial artery; it’s compressed

3. Compression stops blood flow

4. As air is being deflated, cuff pressure decreases

5. Cuff pressure = arterial pressure = blood is flowing again

Checklist for Accurate ‘Office’ BP Measurement

1. The patient should avoid caffeine, exercise, and smoking for at least 30 min before measurement. Ensure the patient has emptied their bladder.

2. Use a blood pressure device that has been validated for accuracy.

3. Use the correct cuff size on a bare arm.

4. The patient’s arm should be supported at heart level.

5. Have the patient relax, sitting in a chair (feet on the floor, legs uncrossed, and back supported) for more than 5 min of rest.

6. Neither the patient nor the clinician should talk during the rest period or during the measurement. The patient should not be using their phone.

7. Blood pressure measurement should be taken in a temperature-controlled room.

8. Take 2 or more blood pressure measurements at least 1 min apart. Average the readings, and provide the patient their blood pressure readings both verbally and in writing.

Normal BP

• Systolic: < 120 mmHg

AND

• Diastolic: < 80 mmHg

Elevated BP

• Systolic: 120-129 mmHg

AND

• Diastolic: < 80 mmHg

High BP — HTN Stage 1

• Systolic: 130-139 mmHg

OR

• Diastolic: 80-89 mmHg

High BP — HTN Stage 2

• Systolic: 140 mmHg or higher

OR

• Diastolic: 90 mmHg or higher

High BP — Hypertensive Crisis (consult dr. immediately)

• Systolic: > 180 mmHg

AND/OR

• Diastolic: > 120 mmHg

How long after taking a patient’s bp should they have a follow-up?

2 weeks (1 week if bp is abnormally high)

Popliteal pulse

Below knee cap

Pedal pulse

Foot

Radial pulse

Wrist

Brachial pulse

Under bicep

Carotid pulse

Neck

In a SOAP note, how are medication lists written?

Drug (generic name), dose, ROA, frequency

• Aspirin 81mg po daily

• Albuterol 90mg MDI, inhale 1 puff po q4h prn

What abbreviations are inappropriate when describing medications in a SOAP note?

QD, SQ

When are medical terms use in a SOAP note’s objective section?

• HPI → mix of medical terms and patient’s wording (e.g., “patient describes palpitations as heart racing out of chest”)

• PMH

• FH

Mitral valve

Allows blood to flow from left atrium to left ventricle

Aortic valve

Between left ventricle going out into the aorta

Tricuspid valve

Between right atrium and right ventricle

Pulmonic valve

Between right ventricle and pulmonary artery (where blood perfuses into lungs)

Where is PMI (point of maximal impulse) located in the heart?

Apex in the 5th intercostal space; bottom tip of the heart (where apical pulse is)

Where is the ‘base’ of the heart located?

At the top of the heart

Midsternal line (MSL)

Midclavicular lines (MCL)

Anterior axillary lines

Intercostal spaces (ICS)

Where is the aortic valve heard best?

On the right side, at 2nd ICS

Where is the pulmonic valve heard best?

On the left side, at 2nd ICS

Where is the tricuspid valve heard best?

Midsternal line, at 4th ICS

Where is the mitral valve heard best?

At PMI (apex of the heart), at 5th ICS

Cardiac Exam: Inspection

• Coloration — signs of cyanosis (blue/gray)

• Pulsations

  • Neck: carotids and internal/external jugulars

  • Point of Maximal Impulse (PMI)

• Heaves, lifts (where heart is beating/rising)

Cardiac Exam: Palpation

Where:

• Carotids

• Valves, left sternal border

What:

• Heaves, lifts (where heart is beating/rising)

• Thrills

• PMI

  • Displaced to the left

  • Diameter (for larger people)

*Percussion is usually skipped

Cardiac Exam: Auscultation

• Carotid bruits — pt holds their breath (use bell of stethoscope)

• Listen in order over all valve areas with diaphragm of stethoscope

• Concentrate on each part of cardiac cycle in isolation

• RRR: Regular Rate Rhythm (heart beating normal)

• M/R/G: Murmurs/Rubs/Gallops (DON’T WANT TO HEAR)

S₁

• Made by: Closure of mitral and tricuspid vales

• During: Start of systole

• Listen with: Diaphragm

S₂

• Made by: Closure of aortic and pulmonic valves

• During: End of systole

• Listen with: Diaphragm

S₃ (extra heart sound)

• Made by: Ventricular filling

• During: Early diastole

• Listen with: Bell

S₄ (extra heart sound)

• Made by: Ventricular filling by atrial kick

• During: Late diastole

• Listen with: Bell

What sound does S₁ make?

“Lub”

What sounds does S₂ make?

“Dub”

What sound does S₃ make?

SLOSH-ing-in (‘lub-dub-ta’)

• Murmur

What sounds does S₄ make?

a-STIFF-wall (‘ta-lub-dub’)

• Inadequate contraction

When are murmurs considered ‘normal'?

In kids, teens, pregnancy

Arterial Insufficiency

Pale, punched-out ulcers, painful distally, elevation hurts

Venous Insufficiency

Black/blue, painless, elevation helps

Vascular Exam: Inspection

Inspect extremities for signs of arterial or venous insufficiency

• Skin discoloration or mottling (signs of cyanosis)

• Dry, scaly skin

• Hair loss (from lack of blood flow)

• Poor nail growth (from lack of blood flow)

• Ulceration (if not healing, from lack of blood flow)

• Varicose veins (venous)

• Edema (venous)

Vascular Exam: Palpation: Pulses

Palpate pulses in major arteries

Note symmetry & warmth of extremities

• Carotids (if not done in cardiac exam)

• Radials ± brachials

• ± abdominal aorta and femorals

• Bilateral dorsalis pedis ± posterior tibial ± popliteal

Pulse Intensity Grading

0 → Absent

1+ → Diminished

2+ → Normal

3+ → Increased

4+ → Bounding

Vascular Exam: Auscultate Bruits

• R, L carotid arteries

• R, L temporal arteries

• R, L subclavian arteries

• Abdominal aorta

• Renal arteries

• Iliac arteries

• Femoral arteries

*Bruits represent stenosis or aneurysm

Vascular Exam: Palpation

Capillary refill time

• Press nail bed for several seconds

• Release

• Color should return within 2 seconds

Vascular Exam: Palpation: Edema

Measuring edema — how deep, how high

• 0+ → No pitting

• 1+ → Mild pitting, 2mm depression that disappears rapidly

• 2+ → Moderate pitting, 4mm depression that disappears in 10-15 seconds

• 3+ → Moderately severe pitting, 6mm depression that may last more than 1 minute

• 4+ → Severe pitting, 8mm depression that can last more than 2 minutes

JVP

Jugular venous pressure

HJR

Hepatojugular reflux

Vascular Exam: ABI

Ankle:Brachial Index (ABI)

• Patient supine

• Palpate dorsalis pedis or posterior tibial systolic brachial pulse (ankle cuff) and brachial systolic brachial pulse

• Use ultrasound probe

• Ankle:arm ratio normally >/ 1

Low ABI = decreased blood flow

1 in ___ people have asthma.

12

Asthmatic lung

Chronic inflammation — feels like you can’t breathe

COPD lung

Airflow limitation not completely reversible; damaged alveoli, can’t function properly

• Bronchitis — ‘Blue Bloaters’

• Emphysema — ‘Pink Puffers’

Characteristics of Chronic Bronchitis

Clinical diagnosis: daily productive cough for 3 months or more, in at least 2 consecutive years

• Overweight and cyanotic (lack of O₂)

• Elevated hemoglobin

• Peripheral edema

• Rhonchi and wheezing

Characteristics of Emphysema

Pathologic diagnosis: permanent enlargement and destruction of airspaces distal to the terminal bronchiole

• Older and thin

• Severe dyspnea (SOB)

• Quiet chest

• X-ray — hyperinflation with flattened diaphragms (normally curved)

Paroxysmal Nocturnal Dyspnea

Waking up in the middle of the night with shortness of breath

Orthopnea

Shortness of breath while lying down, that is relieved by sitting or standing up

Symptom Differentiation in COPD & HF

COPD

• Coughing up mucusy fluid

• Orthopnea (usually w/ 3 pillows); more likely than Paroxysmal Nocturnal Dyspnea

HF

• Coughing up fluid from lungs that appear frothy

• Orthopnea; Paroxysmal Nocturnal Dyspnea

Physical Exam: Inspection & Palpation

Inspection — shape and symmetry

• Respiratory rate (rate, rhythm, depth and ease of breathing)

• Using neck or accessory muscles to help with inspiration

• Signs of cyanosis (look at fingertips, ears, nose, lips)

Palpation

• Thoracic Expansion: ensure chest expands symmetrically

• Tactile Fremitus: feeling lungs inflate at the same time

How many lobes are in the left lung?

2

How many lobes are in the right lung?

3

Tactile Fremitus

Ask patient to say “99” and feel for vibrations — should feel equal on both sides

Physical Exam: Percussion

• Evaluate the density of the lung tissue

  • Lungs are hollow UNLESS there’s a problem

• Order of lobes to tap:

  • Upper

  • Upper

  • Middle

  • Middle

  • Lower

  • Lower

Physical Exam: Ausculation

• Posterior chest at 9 different points

• One full respiration at each location

• Compare side to side (left → right)

• Wheeze vs Crackle

• Bronchophony, egophony, whispered pectoriloquy